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Home My WebLink AboutClosed Epicurean @ 9Hampshire St. 12/31/2016I Date received: I 1) Establishment Name I 2) Establishment Address FOR BOARD OF HEALTH USE ONLY Date Inspected: Approved By: Permit # Issued FS -17 FOOD ESTABLISHMENT PERMIT APPLICATION i7ica io sf Fe s � easi3G! days -be e nnec�opening dafe) EPICUREAN FEA @ IEN-TYCO 9 HAMPS 3) Establishment Mailing Address (if 4) Establishment Telephone No 5) Applicant Name & Title: LPM 6) Applicant Address 24 MAI 7) Applicant Telephone No.: (978) 3r ;re t) 9 HAMPS E S EE ' MANSF A 02048 8 261-8000 ING CO., IN -REET, MAYNARD, MA 01754 24 flour Emergency No.: (978) 375-4899 (774) 284-3071 8) Owners Name & Title LPM HOLDING CO., INC. 9) Owner Address (If different from applicant) 24 MAIN STREET, MAYNARD, MA 01754 Owner's telephone number (978):897-0660 10) Establishment Owned By: 11) If a corporationor partnership, give name, title, and home address of officers ❑ An Association or partner. W A Corporation Name Title Address t C_ Y c� I ( u t O An Individual C3 _ L i t d - I it f . ❑ A Partnership ❑ Other legal Entity 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: MARMIRETBOW-3- WC C3< Address: „�.��...�T-- ��i, i66 t= g - ---- - Telephone No: ( @ Hour Emergency No: (978) 375-4899 (774) 284-3071 FAX: (978) 897-3719 E-mail - -- (s) aft L Alt E -Mail: - 13) District Or Regional Supervisor if applicable) 1 Name & Title: !ROSS QUEENAN Address: Telephone No MAIN STREET, MAYNARD, MA 01754 24 Hour Emergency No: (978) 375-4699 RQUEENAN@LPMHCI.COM 78) 897-0660 FAX: (978) 897-3719 E-mail: Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: 0 17) DAYS/HOURS: 6:30 AM -1:30 PM 18) Name of Person In Charge Certified in Food Protection Management: If more than 3 individuals are certified, complete list is on file. Required as of 10/1/2001 in accordance with 105 CMR 590.003(A) Please attach copy of certificate 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): 20) Location: Permanent Location 22) Establishment Type ❑ Moblie Moblie Start Date: ❑ Retail ( Sq. Ft) Moblie End Date: ❑ Food Service up to 100 or Moblie Comments: up to 10' PHF display $62.50 21) Length of Permit: V Annual ❑ Seasonal Seasonal Dates: LJ Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: Food Service up to 101 -200 or up to 25' PHF display $75.00 ❑ Food Service up to 201 + or 25'+ PHF display $137.50 Food Service - Institution 4100 Meals/Day) ❑ Caterer $12.50 F-/1 Milk & Cream $5.00 ❑ Mobile Food & Consession $37.50 ❑ Manufacture Frozen Desserts/Ice Cream $12.50/freezer ❑ Pushcart $12.50 # of Pushcarts: ❑ Residential Kitchen $50.00 ❑ Retail Food $50.00 ❑ Retail Snack Food $12.50 ❑ Tobacco Products $12.50 23) Food Operations Definitions: PHF - Potentially hazardous food (time/temperature controls required) Non-PHFs - non -potentially hazardous food(no time/temperature controls required) (Check all that apply): j RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) ❑ Sale of Commercially Pre -Packaged Non-PHFs ❑ Sale of Commercially Pre -Packaged PHFs ❑ Delivery of Packaged PHFs ❑ Reheating of Commercially Processed Foods for Service Within 4 Hours ❑ Customer Self -Service of Non PHF and Non - Perishable Foods Only W PHFCooked To Order ❑ Preparation of PHFs For Hot And Cold Holding For Single Meal Service ❑ Sale of Raw Animal Foods Intended to be Prepared by Consumer Customer Self -Service Ice Manufactured and Packaged for 0 Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service ❑ PHF and RTE Foods Prepared For Highly Susceptible Population Facility ❑ Vacuum Packaging /Cook Chill Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health J Preparation of Non-PHFs Retail Sale control) -- Other Food Operations ❑ Juice Manufactured and Packaged for [:]Offers Raw Or Undercooked Food Of Retail Sale Animal Origin 10 Offers RTE PHF in Bulk Quantities �V Prepares Food/Single Meals for __— _ -, Catered Events or Institutional Food Service ❑ Retail Out -Of -Date Reconditioned Food ort To be completed by the Board of Health Total Permit Fee: { $75.00 Payment is due with application waived I, the undersigned, attest to the accuracy of the information provided in thispp application and affirm that g y p pp at the food establishment operation will comply with 105 CMR 590.000 and all other applicable law. I have been instructed by the board of health on how to obtain copies of 105 CMR 590.000 and the federal Food Code. 24) Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I certify 'under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid state taxes required under law. 25) Social Security Number or Federal ID: 04-2273500 . (3 r 26) Signature of Individual or Corporate Name: F,, f m! Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Application for Milk and Cream Permit I hereby make application for a MILK AND CREAM PERMIT, which expires on June 1st of each year. NAME OF BUSINESS: EPICUREAN FEAST @ COVIDIEN-TYCO ADDRESS: 9 HAMPSHIRE STREET TELEPHONE AT LOCATION: (508) 261-8000 FAX NUMBER: OWNER OF BUSINESS: (978) 897-3719 LPM HOLDING CO., INC. TELEPHONE OF OWNER: (978) 897-0660 FEDERAL ID/SS NUMBER: 04-2273500 FEE: $5.00 PERMIT NUMBER: FS -17 SIGNATURE: DATE: certify under the penalties of perjury that I, to my best knowledge and belief, have filed all State tax returns and paid all State taxes required under law. * Signature of Individual r Corporate Name (Mandatory) iLOa�QA By: Co orate Offir (Mandatory, if applicable) ** Social Security Number (Voluntary) or Federal Identification Number * This license will not be issued unless the certification clause is signed by the applicant. ** Your Social Security number will be furnished to the Massachusetts Department of Revenue to determine whether you have met tax filing or tax payment obligations. Licensees who fail to correct their non -filing or delinquency will be subject to license suspension or revocation. This request is made under the authority of Mass. General Laws, Chapter 62C, Section 49A. The Commonwealth, of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Business/Organization Name: 0—! �4 ( 1' fN co, Address: ,� P��t lt) &4- City/State/Zip: &[.k j iG�_ ifUa (.l Iq�4 Phone Are yup an employer? Check the appropriate box: ,_ 1. D I am a employer with. employees (full and/ or part-time).* 2, ❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp, insurance required] 3. ❑ We are a corporation and its officers have exercised their right of exemption per c, 152, § 1(4),and we have no employees. [No workers' comp. insurance we 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers', comp. insurance req.] M Business Type (required): 5. ❑ Retail 6. ❑ Restaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl, real estate, auto, etc.) 8. ❑ Non-profit 9, ❑ Entertainment 10.❑ Manufacturing 11.0 Health Care 12.[1 Other 6- F -e *Any applicant that checks box #I must also fill out the section below showing their workers' compensation policy information, **If the corporate officers have exempted thcroselves, but the corporation has other employees, a workers' compensation policy is required and such an organization should check box #1. I am an employer that is providing workers' coAnpensadon insurance for my employees. Below is the policy information. Insurance Company Insurer's Address: , • o . b c A��' � t City/State/Zip: �� (( � t )\ , Policy # or Self -ins, Lic. # �i" ® o Q "i c1Expiration Data: 111111 Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c, 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify, under the pains and pfnalties of perjury that the information provided above is true and correct: Official use only. Do not write in this area, to he completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone www,moss.gov/aia /�C 1 ® CERTIFICATELIABILITY INSURANCE DATE (MM/DDNYYY) 4/14/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. if SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Roger Keith & Sons 1575 Main Street P.O. Box 3067 Brockton MA 02304 CNAOME:NT T Janelle Litto Pac°No Ext: (508)583-1106 No: (508)583-8478 E-MAIL ADDRESS: erkeith.com ADDRESS: � g _ INSURERS) AFFORDING COVERAGE NAIC # INSURERA:Travelers PropertV & Casualty Ins. TPCO01 INSURED LPM Holding Co. Inc. DBA EPICUREAN FEAST 24 Main Street Maynard MA 01754 INSURER B :Charter Oak Fire Iris Co 25615 INSURERC:FEDERAL INSURANCE INSURER D :MA RETAIL MERCHANTS WC GROUP INSURER E :NH ASSOCIATION MEMBERS WCT A INSURER F: nnvC0An=Q r PnT1FICATF NIIIUIRFR-2016 EPICUREAN MASTER REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR TYPE OF INSURANCE AD S BA POLICY NUMBER POLICYEFF POLICY YYY LIMBS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS -MADE a OCCUR DAMAGE TO RENTED (Ea occurrence) $ 1,000,000 -PREMISES MED EXP (Any one person) $ 10,000 63060830447 1/1/2016 1/1/2017 PERSONAL SADV INJURY $ 1,000,000 INCLUDES LIQUOR LIABILITY GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000 $1,000,000 LIMIT PRODUCTS - COMP/OP AGG $ 2,000,000 X POLICY 1 PRO- El LOC JECT Liquor Liability $ 1,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 Ea accident BODILY INJURY (Per person) $ B ANY AUTO SCHEDULED XAUTOS AUTOS ALL OWNED Ix NON -OWNED HIRED AUTOSAUTOS 81070399675 $1,000 DEDUCTIBLES 1/1/2016 1/1/2017 BODILY INJURY (Per accident) $ PROPERTYDAMAGE$ Per accident A X UMBRELLA LIAB X OCCUR ZUP91M4890816 1/1/2016 1/1/2017 EACH OCCURRENCE $ 25,000,000 AGGREGATE $ 25,000,000 C X EXCESS LIAB CLAIMS -MADE DED I X I RETENTION 10,000 35,000,000 $ 35, 000, 000 79882528 1/1/2016 1/1/2017 A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOWPARTNER/EXECUTIVE Y / N OFFICER/MEMBER EXCLUDED? (Mandatory In NH) N/A pJUB6C87139-8-16 1/1/2016 1/1/2017 X IPER STATUTE OTH- ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYE $ 1 000 000 E.L. DISEASE - POLICY LIMIT $ 1,000,000 IfDESCyes, Rdesc IPTribeION under OF OPERATIONS below AZ, CT, ME, NJ, NY, PA, RI D WORKERS COMP. MA ONLY 014000502016116 1/1/2016 1/1/2017 1,000,000/1,000,000/1,000,000 E WORKERS COMP. NH ONLY 030009100240116 1/1/2016 1/1/2017 1,000,000/1,000,00011,000,000 DESCRIPTION OF OPERATIONS/ LOCATIONS/ VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) POLICY LIMITS IN EFFECT AT POLICY INCEPTION e'CQT!cl('ATG unl nFR CANCELLATION ACORD 25 (2014/01) INS025 (201401) 9 1988-2014 AUUHU GUhll'UHA I IUN. An ngnrs reservea. The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TOWN OF MANSFIELD 6 PARK ROW THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. MANSFIELD, MA 02048 AUTHORIZED REPRESENTATIVE DONOVAN DUNN/KEIJJI - ACORD 25 (2014/01) INS025 (201401) 9 1988-2014 AUUHU GUhll'UHA I IUN. An ngnrs reservea. The ACORD name and logo are registered marks of ACORD Ln C O C ^ E °- u. u C r- O .0 m 4_ o O O. (/ 0 O c O U- 0 ° ro � u c C o m u p O c fCf � � u 0 V) N C J N i ro ro 0 fJ �p to = 7_ q z ary ui o ®CN a a uj LU Qj /'y N W0uj Q p Q C {Oj N l y � N N ffi.t O N. N m m2 ae �ryry ? G p � r `v Z, 0 � z Chi . w � � p p . 0e N 0 � =o _ LO _ LO �� a oa;m V ,42 sm m